Fulminant Parvovirus B-19 Infection Manifesting as Acute Encephalitis Syndrome and Myocarditis in a 10-Year-old Boy

To the Editor: Parvovirus B-19 infection commonly presents with skin, joint and hematological manifestations. Acute encephalitis and myocarditis are rare presentations and concurrent manifestation of both is extremely rare. We report a case of 10-year-old boy presenting as acute encephalitis syndrome (AES) with recurrent episodes of cardiac arrhythmias and myocardial dysfunction without any other identifiable underlying cause. Parvovirus B-19 DNA polymerase chain reaction was positive in cerebrospinal fluid (CSF). Administration of intravenous immunoglobulin (IVIg) possibly led to improvement in cardiac function; however, improvement in sensorium was modest. A 10-year-old boy presented with fever, vomiting and headache for 2 days and altered sensorium with left eye ptosis for 12 hours. At the presentation, the vitals were normal. On central nervous system (CNS) examination, the Glasgow Coma Scale was 8/15, pupils were mid-dilated, reactive to light and there was no papilledema. There was left eye ptosis, deep tendon reflexes were brisk and meningeal signs were positive. He was managed as a case of AES with raised intracranial pressure and required mechanical ventilation. The initial computed tomography scan was normal. CSF examination demonstrated 40 cells (50% neutrophils), increased proteins (140 mg/dL) and low sugar levels (30 mg/dL). On day 2, he developed wide complex ventricular tachycardia requiring synchronized cardioversion, intravenous metoprolol, lidocaine and amiodarone infusion. The ejection fraction was 35% and cardiac enzymes were raised (Creatinine Kinase-MB-1075 IU/L, positive Troponin I). He was administered IVIg along with intravenous corticosteroids. Cardiac manifestations resolved in 3 days but encephalopathy persisted. The CSF viral panel was positive for parvovirus B-19 DNA polymerase chain reaction. Contrast-enhanced magnetic resonance imaging brain revealed involvement of multiple areas of brain including bilateral temporal lobes, right parietal lobe and bilateral cerebellar hemisphere showing diffusion restriction and post-contrast enhancement suggestive of encephalitis and cerebellitis (Fig. 1). Tracheostomy was done and child was weaned off from ventilator. However, severe neurologic sequelae persisted at discharge.FIGURE 1.: Magnetic resonance imaging (MRI) brain showing. A: Gyral thickening involving bilateral temporal lobes showing hyperintense signal on FLAIR images. B: Diffusion restriction in DWI. C: Patchy FLAIR hyperintensities in bilateral cerebellar lobes. D: Diffusion restriction in DWI. E: Dependent debris in lateral ventricles showing diffusion restriction in DWI. F: Lacunar infarcts showing diffusion restriction in DWI involving splenium of corpus callosum. G: Leptomeningeal enhancement along ventral aspect of brainstem and spinal cord (white arrows). H: Nodular enhancement in left external capsule (white arrows). DWI indicates diffusion-weighted images; FLAIR, fluid-attenuated inversion recovery.The classical manifestation of B19V infection includes erythema infectiosum, multisystem involvement with anemia, thrombocytopenia, hepatitis, arthropathy and transient aplastic crisis. Serious manifestations of B19V infection include neurological and cardiac dysfunction owing to its viral cytopathic effect. The data regarding CNS manifestations of B19V infection in children is scarce.1 Acute encephalitis and encephalopathy are the most common neurological manifestations, accounting for 33.8% of B19V-associated CNS infections.2 The outcomes of B19V encephalitis are often poor and 31% patients of all age groups were reported to have persistent neurologic defects. There was no statistically significant difference in the rates of sequelae or death between those who received IVIg and/or steroids and those who were not treated with any immunomodulatory therapy.3 B19V myocarditis is a life-threatening manifestation in children with arrhythmias occurring in 15.6% children.4 The administration of immunosuppressive drugs and immunoglobulin administration is correlated with good outcomes in pediatric patients with B19V-associated myocarditis.5 However, B19V myocarditis also causes significant mortality and morbidity with 37.5% deaths and only 26% children having complete recovery of cardiac function.4,6 Fulminant presentation of human Parvovirus B-19 virus causing simultaneous acute encephalitis with myocardial dysfunction is extremely rare. Still, it is important to consider Parvovirus B-19 as a cause of pediatric AES and myocardial dysfunction. Administration of IVIg along with supportive management may reduce the morbidity and mortality.